Ask Our Doctors – Archive
Our Medical Directors are outstanding physicians that you will find to be very personable and compassionate, who take care to ensure that you have the most cutting-edge fertility treatments at your disposal. This is your outlet to ask your questions to the doctors.
Dear Dr. Sher,
I was wondering if you could suggest what IVF protocol might be best for me? I’ve just underwent my first IVF (long lupron protocol) and unfortunately it was not successful (PGS showed all 5 blastocysts are chromosomally abnormal). Details about the protocol I followed: BC pills for 6 weeks, 10 mg of lupron for 10 days, then lupron was cut to 5 mg. Started Gonal-F = 300 & Menapur=150 for 4 days, then Gonal-F was increased to 375 units for another 5 days (Menapur stayed the same 150). On the last, the 10th day, a dose of Lupron (5mg) and trigger shot – Ovidrel. The results were: 22 follicles, 17 eggs were retrieved; 14 of them were mature and injected with sperm (ICSI). Only 9 fertilized, only 5 reached blastocyst stage (A and B grade). PGS showed all 5 of them chromosomally abnormal. About me: I am 39 year old; AMH = 1.352; FSH=5.7; LH=2.8; Prolactin = 24.6; TSH = 3.17; Estradiol = 37. I understand that my age is the major factor in embryo quality; but I was wondering what would be an optimal protocol in my situation? Thanks a lot for your very informative blog and article!
Hi Elena,
Frankly this is not a bad protocol. I might have modified it slightly by giving more Gonal-F upfront but less Menopur (perhaps 75U. The big issue is a) the implementation and b) the dosage of recombinant hCG (Ovidrel). If 500mcg (2 vials was used, that is fine but if (as I suspect) the dosage was only 250mcg (one vial) then in my opinion, that is too low a trigger dosage. The problem it causes when the dosage is too low, is in my opinion, that the stimulus for meiosis (reproductive division) is suboptimal, leading to a much greater risk of egg aneuploidy.
My advice is to use a long pituitary down regulation protocol starting on a BCP, and overlapping it with Lupron 10U daily for three (3) days and then stopping the BCP but continuing on Lupron 10u daily (in my opinion 20U daily is too much) and await a period (which should ensue within 5-7 days of stopping the BCP). At that point an US examination is done along with a baseline measurement of blood estradiol to exclude a functional ovarian cyst and simultaneously, the Lupron dosage can be maintained or be reduced to 5U daily and continued until the hCG (10,000u) or Ovidrel 500mcg, “trigger”. An FSH-dominant gonadotropin such as Follistim, Puregon or Gonal-f daily is started with the period for 2 days and then the gonadotropin dosage is reduced and a small amount of menotropin (Menopur—no more than 75U daily) is added. This is continued until US and blood estradiol levels indicate that the hCG trigger be given, whereupon an ER is done 36h later. I personally would advise against using Lupron in “flare protocol” arrangement (where the Lupron commences with the onset of gonadotropin administration.
I strongly recommend that you visit https://www.drgeoffreysherivf.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
• The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
• Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
• IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation (COS)
• The Fundamental Requirements For Achieving Optimal IVF Success
• Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas
• Should IVF Treatment Cycles be provided uninterrupted or be Conducted in 7-12 Pre-scheduled “Batches” per Year
• A personalized, stepwise approach to IVF
• “Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:
If you are interested in seeking my advice or services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com You can also apply online at http://www.SherIVF.com .
*FYI
The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD
Hi Dr. Sher,
Do you think that Menopur is contraindicated in some cases? I have had two chemicals in a row and I can´t help but wonder if it has anything to do with the LH in the Menopur ( 1st cycle was CC+Menopur and 2nd cycle was Letrozole+Menopur), both with Pregnyl and timed intercourse. I am 30yrs old and have polycystic ovaries.
I would also love your opinion on whether I can start meds right away after a chemical, even if my hcg is not zero? First day of period was today, planning on starting CC on day 3, but my hcg yesterday was 13. So I guess it would not be zero by Sunday. Is that ok or would it interfere with my cycle?
Thank you so much, as always.
I would not start a stimulation until your blood hCG is down to “Zero”. In my opinion, a combination of clomiphene/letrozole + Menopur will deliver a high LH impact on the ovaries. This is because both clomiphene and letrozole propagate a high output of pituitary LH and Menopur adds LH /hCG to the mix.
Geoff Sher
Hi Dr Sher
What is the name of the test for antibodies phosphoethanolamine and phosphoserine? Is amniocentesis safe for the baby if NIPT test not available in my hospital? Does TSH test rule out the first trismester thyroid problem in pregnancy?
Regards,
Silvia
1. What is the name of the test for antibodies phosphoethanolamine and phosphoserine?
A: Test for antiphospholipid antibodies. There are fewer than a half dozen Reproductive Immunology laboratories in the U.S. that can do this test with sufficient sensitivity and specificity to make it of value. I use Reprsource in Boston, MA.
2. Is amniocentesis safe for the baby if NIPT test not available in my hospital?
A: In my opinion , yes!
3. Does TSH test rule out the first trismester thyroid problem in pregnancy?
A: No because the underlying immunologic cause still prevails and if you have antithyroid antibodies, there is in my opinion, a 50% chance that you would have an immunologic implantation dysfunction (IID) linked to activation of uterine natural killer cells!
Geoff Sher
Dr Sher, hi…you probably don’t remember me since it has been over 10 years since we last communicated. Back then I was a 20year old girl who was diagnosed with ovarian failure/primary infertility/early menopause. You were the first person to tell me that I am a Chernobyl child, and thats why everything in my body is conflicting. So here I am now, 11 years later, and 8 years after having had a failed donor egg IVF, looking for your advice. My bloods remain the same (FSH >80 , estradiol level very low), ovaries and uterus really small. I was told in March (2018) that I might be pregnant because all the symptoms I had were pointing that direction, but unfortunately that wasn’t the case, however, it seems that my ovaries are showing signs that they want to start working again, although i am still under HRT with Cyclo Progynova. Is this even possible from a conventional medicine point of view?
Sadly , not in my opinion, Dianna!
You would need IVF using an egg donor~!
Geoff Sher
hi, dear sher. sorry for asking so many questions.I am 40 years old. all my hormone levels are good . theres no DOR. i asked my doctor to use HGH in my next protocol buy she told me that it wont make any difference in my situation cause that i havnt got DOR. what u think about this. do u use HGH in old but good overian reserved patients . do u use dhea in this patients. ?
thank u for all replies. god bless u. 🙂
Yes I do! Your Dr is correct, it has not been shown conclusively that HGH helps, but I believe it does (in my experience).
Geoff Sher